PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based
services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.

The waiver application is based on the HCBS Quality Framework. The Framework focuses on seven broad, participant-centered desired outcomes for the delivery of waiver services, including assuring participant health and welfare:
• Participant Access: Individuals have access to home and community-based services and supports in their communities.
• Participant-Centered Service Planning and Delivery: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community.
• Provider Capacity and Capabilities: There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.
• Participant Safeguards: Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.
• Participant Rights and Responsibilities: Participants receive support to exercise their rights and in accepting personal responsibilities.
• Participant Outcomes and Satisfaction: Participants are satisfied with their services and achieve desired outcomes.
• System Performance: The system supports participants efficiently and effectively and constantly strives to improve quality.

For More Information Regarding the HCBS Waiver please see:
http://www.dhs.state.mn.us/main/groups/aging/documents/pub/dhs16_143051.pdf

Exposure to Antipsychotics and Risk for Stroke
Use of antipsychotics, especially atypical drugs, raises risk for stroke, and this risk is higher in patients with dementia than in those without.
During 2002, analysis of clinical trial data raised concerns that exposure to the atypical antipsychotic drug risperidone led to excess stroke risk in dementia patients. However, whether stroke risk associated with antipsychotic drug exposure differs among people with or without dementia is unknown. Using a large database that predated these concerns, U.K. investigators compared stroke incidence during periods of exposure and nonexposure to antipsychotic drugs within individual patients who had or did not have dementia.
Of 6790 patients who had first strokes and were prescribed antipsychotic drugs between 1988 and 2002, 6334 were prescribed at least one typical drug (most commonly phenothiazines), and 905 patients were prescribed at least one atypical drug (most commonly risperidone). The median age at first exposure to any antipsychotic drug was 80, and the median age at first stroke was 81. Exposure to any antipsychotic drug was associated with significantly higher risk for stroke (rate ratio, 1.73); excess risk was noted for both typical drugs (RR, 1.69) and atypical drugs (RR, 2.32). In patients with dementia, exposure to any antipsychotic drug was associated with a rate ratio for stroke of 3.50, whereas, in patients without dementia, the rate ratio was 1.41. In all analyzed groups, the rate ratios decreased towards 1.0 during the 5 months after treatment ended.
Comment: Exposure to antipsychotic drugs is associated with excess risk for stroke, and this risk appears to be higher among patients with dementia than among those without dementia. Notably, the mechanism by which these drugs raise stroke risk is unclear. Nevertheless, these results should serve as yet another red flag for clinicians, joining those of recent studies that showed minimal efficacy in patients with dementia who received antipsychotic drugs (JW Dec 28 2006).
— Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine September 11, 2008
Citation(s):
Douglas IJ and Smeeth L. Exposure to antipsychotics and risk of stroke: Self controlled case series study. BMJ 2008 Aug 28; 337:a1227. (http://dx.doi.org/10.1136/bmj.a1227)

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Lawmakers look at sex offenders in nursing homes
Updated 7/24/2008 11:29 PM l | Save | Print | Reprints & Permissions |

By Julie Appleby, USA TODAY
Ray McDaniel’s 18-year-old daughter was raped 10 days after moving into a nursing home — by a registered sex offender who also lived there.
No one was required to tell McDaniel that the 43-year-old sex offender was a resident of the nursing home where his daughter was admitted in 2005 because she is mentally retarded and has schizophrenia. The resident who attacked her pleaded guilty and is serving three years in prison.
His daughter’s case led to an Ohio legislative proposal to require nursing homes to post notices if sex offenders live there. The bill has been adopted by the Ohio House and awaits a Senate hearing.
Every state, McDaniel says, should require facilities to “tell people if there is a sex offender in this nursing home.”
Ohio is one of several places reviewing notification procedures for sex offenders living in long-term care facilities. The issue is drawing attention as overall nursing home populations drop and some facilities see an influx of residents with mental illnesses, says Beverley Laubert, president of the National Association of State Long Term Care Ombudsman Programs, which help protect patient rights. While the majority of nursing home residents are older than 65, it’s not unusual for younger people with medical problems to live in long-term care.